Customer Service Navigator

Bayside Solutions; California; Hybrid; USD 37,000 - 46,000; Full time

Job summary

Bayside Solutions in South San Francisco, CA offers a hybrid role as a Customer Service Navigator. You will respond to member and provider inquiries by phone and other channels, delivering prompt, accurate information about benefits, eligibility, and services.

The role emphasizes HIPAA-compliant handling of sensitive health data, seamless escalation, and coordination with care teams. 1+ year in healthcare or public service is preferred, with bilingual capabilities highly valued.

Qualifications

• High school diploma or GED required.
• 1+ year of experience in customer service or call center, preferably in healthcare.
• Experience with Medi-Cal and Medicare preferred.
• Microsoft Office products knowledge (Word, Excel, PowerPoint, Outlook).
• Bilingual skills in Spanish, Mandarin, Cantonese, or Tagalog required.
• Ability to maintain health information confidentiality per HIPAA.

Responsibilities

• Handle high-volume inbound and outbound calls and other communications with members and providers.
• Follow scripts and guidelines while protecting confidential information per HIPAA.
• Explain eligibility, benefits, and provider networks to members and assist with PCP selection and changes.
• Document all interactions accurately in accordance with policies and procedures.
• Escalate issues to appropriate departments and coordinate care coordination referrals as needed.

Skills

Customer service

Call center

Healthcare knowledge

Bilingual

Microsoft Office

HIPAA compliance

Education

High school diploma or GED

Tools

Microsoft Word

Excel

PowerPoint

Outlook

Job description

Customer Service Navigator

Contract: W2 Contract

Pay Rate: $26.59 - $33.59 per hour

Location: South San Francisco, CA - Hybrid Role

Job Summary

Under direct supervision, respond to our member and provider inquiries by telephone and other communication channels, providing members with comprehensive support regarding health plan benefits and services. Acts as the primary point of contact for members, delivering prompt, accurate, and courteous assistance via telephone and other communication channels, whether for general inquiries, concerns, or information requests about our programs, services, eligibility, or benefits.

Duties and Responsibilities

• Handle inbound and outbound calls and other communications in a high-volume environment, providing excellent customer service and professionalism, in accordance with established policies and procedures, and meeting established performance and quality metrics.
• Adhere to established guidelines, call scripts, and resources to address member and provider inquiries; this includes maintaining the confidentiality of member information and complying with HIPAA and other relevant regulations. For non-routine inquiries, leverage available resources and expertise to resolve issues that fall outside standard protocols.
• Resolve concerns accurately, promptly, professionally, and with cultural competence; ensure that explanations are appropriate to the member's level of understanding and knowledge.
• Intake, handle, and coordinate member grievances, appeals, and billing issues, escalating to the Grievance and Appeals department when necessary.
• Educate members and providers about eligibility, benefits, and the provider network; assist members in selecting or changing their primary care physician and provide accurate information about available providers and effective dates for PCP assignments.
• Use listening skills and judgment to appropriately categorize and accurately document all interactions and follow-up actions regarding member and provider communications in accordance with established guidelines.
• Refer members to appropriate community partner agencies based on their specific needs, including Behavioral Health and Recovery Services, Aging and Adult Services, Legal Aid, Human Services Agency, and HICAP when applicable.
• Use strong professional judgment to determine when to elevate member or provider inquiries to other departments; share important information and collaborate with teams to resolve issues, including referring members to health services for care coordination.
• Proactively seek opportunities to improve processes and enhance the overall member experience.
• Attend and actively participate in regular departmental meetings, training sessions, and coaching sessions.
• Cross-train on a variety of tasks as requested to ensure continuity of operations.
• Conduct member outreach such as welcome calls and targeted outreach calls as assigned.
• Participate in and represent us professionally at health fairs, community partnerships, meetings, committees, and coalitions as assigned.
• Perform other duties as assigned.

Requirements and Qualifications

• High school diploma or GED
• One (1) or more years of experience in a Customer Service or Call Center role, preferably in a healthcare or public-sector setting
• Previous experience with managed care plans, Medi-Cal, and Medicare programs, and working with underserved populations preferred
• Knowledge of Microsoft Office products, including Word, Excel, PowerPoint, and Outlook
• Knowledge of health insurance and medical terminology
• Bilingual skills in Spanish, Mandarin, Cantonese, or Tagalog required.
• Ability to communicate effectively both verbally and in writing with diverse audiences
• Ability to maintain health information confidentiality and follow HIPAA privacy and security best practices

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate.

Bayside Solutions, Inc. may collect your personal information during the position application process. Please reference Bayside Solutions, Inc.'s CCPA Privacy Policy at www.baysidesolutions.com.

Desired Skills and Experience

Customer Service, Call Center Operations, Member and Provider Support, Inbound and Outbound Calls, Health Insurance, Managed Care, Medi-Cal, Medicare, Benefits Education, Eligibility Verification, Provider Networks, Primary Care Physician Selection and Assignments, Grievances and Appeals, Billing Issue Resolution, Complaint Resolution, Issue Escalation, Member Outreach, Care Coordination Referrals, Community Resource Referrals, Interaction Documentation, HIPAA Compliance, Health Information Confidentiality, Medical Terminology, Cultural Competence, Underserved Populations, Active Listening, Professional Judgment, Problem Solving, Verbal and Written Communication, Cross-Functional Collaboration, Process Improvement, Performance and Quality Metrics, Community Engagement, Microsoft Word, Excel, PowerPoint, Outlook, Bilingual Spanish/Mandarin/Cantonese/Tagalog Preferred